Case Report / Olgu Sunumu Ege Journal of Medicine / Ege Tıp Dergisi 2020; 59 (3): 226-231 Intestinal obstruction caused by internal herniation as a complication of Meckel's diverticulum Meckel divertikülünün bir komplikasyonu olarak internal herniasyona bağlı bağırsak tıkanması Osman Erdoğan1 Ahmet Gökhan Sarıtaş2 Zafer Teke1 Levent Bolat2 İshak Aydın2 1 Cukurova University, Faculty of Medicine, Department of Surgical Oncology, Adana, Turkey 2 Cukurova University, Faculty of Medicine, Department of General Surgery, Adana, Turkey Abstract Meckel’s diverticulum is a prevalent congenital anomaly of the digestive system, with an incidence of approximately 1-3% in the population. Intestinal obstruction is a widespread complication in adults. Patients are often operated on with a preliminary diagnosis of acute abdomen, and Meckel's diverticulum are usually diagnosed during the operation The surgical technique should be planned according to the condition of the patient. In this article, we aimed to present a case of 68-year-old female with mechanical bowel obstruction caused by internal herniation of small intestine as a complication of Meckel’s diverticulum. Statement: Oral presentation at V. International Congress on Natural and Health Sciences (ICNHS- 2019), Adana, Turkey, December 13 to December 15, 2019. Keywords: Meckel’s diverticulum, complication, internal herniation, mechanical bowel obstruction, intestinal obstruction. Öz Meckel divertikülü gastrointestinal sistemin en sık rastlanan doğumsal anomalisi olup genel nüfusta yaklaşık %1-3'lük bir oranda görülmektedir. Bağırsak tıkanıklığı yetişkin hastalarda en sık görülen komplikasyondur. Hastalar sıklıkla akut karın ön tanısı ile ameliyat edilir ve Meckel divertikülü genellikle ameliyat sırasında teşhis edilir. Cerrahi teknik hastanın durumuna göre planlanmalıdır. Bu çalışmada Meckel divertikülünün bir komplikasyonu olarak ince bağırsağın internal herniasyonuna bağlı mekanik bağırsak tıkanıklığı olan 68 yaşında bir kadın olguyu sunmayı amaçladık. Açıklama: 13-15 Aralık 2019 tarihlerinde Adana’da düzenlenen V. Uluslararası Doğa ve Sağlık Bilimleri Kongresi’nde (ICNHS-2019) sözlü bildiri olarak sunulmuştur. Anahtar Sözcükler: Meckel divertikülü, komplikasyon, internal herniasyon, mekanik bağırsak tıkanıklığı, bağırsak tıkanıklığı. Introduction Meckel’s diverticula produce symptoms in only Meckel’s diverticulum is a prevalent congenital 16% of patients (2). This pathologic lesion may anomaly of the digestive system, seen in 2% to lead to bleeding and intestinal obstruction during 3% of the population (1). Most of the cases with childhood, and is incidentally diagnosed in Meckel’s diverticulum are usually asymptomatic. adulthood. Corresponding author: Osman Erdoğan Cukurova University, Faculty of Medicine, Department of Surgical Oncology, Adana, Turkey E-mail: [email protected] Application date: 28.02.2020 Accepted: 08.06.2020 226 It may present with life-threatening complications. noticed in the distal part of the diverticulum. Meckel’s diverticulum often presents itself with Internal herniation of small intestine was mechanical bowel obstruction in adults, and observed. The connection between Meckel's intestinal obstruction is usually caused by diverticulum and lateral abdominal wall was intussusception due to Meckel’s diverticulum. separated by sharp dissection. Internally Less common causes of bowel obstruction herniated small bowel loops were reduced and resulting from Meckel’s diverticulum are fibrous the Meckel’s diverticulum was fully exposed bands, Littre’s hernia, loop formation, strictures, (Figure-1d). There was an anomaly of the and volvulus. diverticular mesentery, and a fibrous stenosis of Here we present a case of 68-year-old female the small intestine just proximal to the with mechanical bowel obstruction due to internal diverticulum was noticed. The small bowel herniation of small intestine resulting from segment with margins of at least 5 cm proximally Meckel’s diverticulum. and distally containing Meckel's diverticulum was Case Report transected by linear staplers, and then a side-to- side small intestinal anastomosis was done. The A 68-year-old female patient presented to patient recovered uneventfully and is doing well emergency room with abdominal pain, nausea at a 3-month follow-up. The histologic and vomiting, inability to discharge gas and examination confirmed the Meckel's diverticulum. stools for two days. Her past medical history No heterotopic tissue was detected in pathologic included type 2 diabetes mellitus. Her previous examination of our patient’s resected specimen. surgical history included appendectomy and Written informed consent was received from the cholecystectomy. The patient had no important patient. family history, and denied alcohol usage or smoking tobacco. Physical examination showed an obvious distention in the abdomen, and a rebound tenderness was detected in the lower quadrants of the abdomen upon palpation. Groin examination revealed no hernia on both sides. Digital rectal examination revealed an empty rectal ampulla. Her bowel sounds were hypoactive. White blood cell count was 15.6 x 103/μL (normal range 3.5 x 103/μL -9.5 x 103/μL) and a C-reactive protein of 19 mg/L (normal range 0-3 mg/L). Multiple air-fluid levels were seen on the upright abdominal X-ray (Figure-1a). Abdominal and pelvic computed tomography (CT) was performed after the intravenous injection of non-ionic contrast material; no oral contrast material was administered. There were multiple dilated low-attenuation fluid-filled loops of the small bowel (Figure-1b). The patient underwent an emergent median laparotomy because of acute abdomen due to mechanical Figure-1 (a) Abdominal X-ray revealing gaseous bowel obstruction. At surgery, a 6-cm length of distension of the small bowel in the left upper abdominal area with paucity of gas in Meckel’s diverticulum was seen on the anti- the lower abdomen, (b) abdominal CT scan mesenteric side of the ileal segment located showing multiple dilated fluid-filled loops of proximally 80 cm away from the ileo-cecal region, small bowel, (c) operative view showing which rotated around its axis and adhered to the Meckel’s diverticulum strangulating the small bowel, and (d) the small bowel right lateral abdominal wall (Figure-1c). Because including Meckel’s diverticulum after full of this rotation, there was a stenosis within the exposure. lumen of ileal loop and a partial ischemia was Volume 59 Issue 3, September 2020 / Cilt 59 Sayı 3, Eylül 2020 227 Discussion umbilicus, abdominal wall or other viscera, or 2) An internal hernia is formed by the protrusion of a the diverticulum is free and unattached. An viscus through a peritoneal or mesenteric attached diverticulum is more likely to obstruct aperture, leading to its encapsulation within a than one remaining free (1). Obstruction may be compartment of the abdominal cavity. The hernial caused by entanglement of the small bowel orifice is usually a preexisting anatomic structure, around a fibrous cord, entrapment of an ileal loop such as the foramen of Winslow or the within a mesodiverticular band, intussusception, paraduodenal fossa. However, congenital volvulus, incarceration within a hernia sac, or anomalies of the intestinal rotation and peritoneal chronic Meckel’s diverticulitis. A mesodiverticular attachments are important factors which band is a vascular cord running between the predispose to internal herniation. Postsurgical or diverticulum and the base of the mesentery. It traumatic defects of the mesentery and omentum predisposes to obstruction by allowing are also potential sites for herniation of intestinal entrapment of a loop of ileum. Intussusception loops. Congenital or acquired internal hernias develops because the diverticulum serves as a account for 0.6 to 5.8 percent of small bowel lead point following simple invagination. obstruction (3). Most commonly, internal hernia However, inversion of the diverticulum into the occurs through mesentery of small intestine. gut lumen may occur without producing any Meckel’s diverticulum causing internal hernia and symptoms or complications. Only anatomically small bowel obstruction is an extremely rare free diverticula can invaginate. Volvulus occurs complication, and it should be considered in when there is a persistent fibrous band, and is patients with obstructive symptoms, especially in related to the shape and degree of fixation of the younger people without previous abdominal diverticular tip. Fixation of the tip may also allow surgery. Haskaraca et al. reported a case of torsion of the diverticulum around its own axis. internal hernia through mesentery of Meckel’s Occasionally, Meckel's diverticula become diverticulum (4). On the other hand, occurrence strangulated within inguinal, or less commonly, of internal hernia and intestinal gangrene due to femoral or umbilical hernias. This has been Meckel’s diverticulum is rare. Zhang et al. termed a Littre's hernia after the author who reported a case of a 45-year old female patient originally described three cases of incarceration who presented with intestinal obstruction and at of small bowel diverticula within femoral hernias laparotomy was found to have Meckel’s (1). A chronically inflamed Meckel's diverticulum diverticulum with internal hernia causing intestinal can cause obstruction when the inflammation gangrene (5). Other causes of internal herniation extends to the adjacent small intestine, producing are due to adhesion of the inflamed tip of cicatricial